It wasn’t on pur­pose. We could not have in­ven­ted an­ti­bi­ot­ics without spur­ring bac­teri­al evol­u­tion. As long as there were some bugs out there im­mune to the drugs, the pop­u­la­tion would ad­apt. Just a few years after an­ti­bi­ot­ics came in­to mass use in the 1940s, sci­ent­ists began to ob­serve res­ist­ance. Then, as mi­cro­bi­o­lo­gist Ken­neth Todar writes, “Over the years, and con­tinu­ing in­to the present, al­most every known bac­teri­al patho­gen has de­veloped res­ist­ance to one or more an­ti­bi­ot­ics in clin­ic­al use.” And now, some bugs are res­ist­ant to just about everything.

Car­bapenem-res­ist­ant En­terobac­teri­aceae, known as CRE or the “night­mare bac­teria,” was not known be­fore 2001. Now, 4.6 per­cent of hos­pit­als in the United States re­por­ted at least one in­fec­tion in 2012. That num­ber was 1.2 per­cent in 2001.

CRE out­breaks are the stuff of zom­bie movies, be­cause no drug ex­ists to fight them. In 2011, at a Na­tion­al In­sti­tutes of Health hos­pit­al no less, an out­break of a CRE vari­ant killed six people. CRE germs kill about half the people they in­fect, but here’s the scar­i­er part: “CRE have the po­ten­tial to move from their cur­rent niche among health care”“ex­posed pa­tients in­to the com­munity,” the Cen­ters for Dis­ease Con­trol and Pre­ven­tion re­ports.

Drug-res­ist­ant patho­gens such as CRE are mainly found in the hos­pit­al set­ting, but they are also found in the en­vir­on­ment. A Columbia Uni­versity study found drug-res­ist­ant germs to be “wide­spread” in the Hud­son River in New York, with the re­search­ers sus­pect­ing the source was un­treated sewage. The more com­monly known MRSA, con­fined to in­fec­tions in hos­pit­als in the first two dec­ades after it was dis­covered, can now be con­trac­ted from every­day sur­faces such as gym mats.

Last week, CDC re­leased the first com­pre­hens­ive re­view of the num­ber of drug-res­ist­ant in­fec­tions and deaths in the coun­try. It’s the first of its kind, com­pil­ing data from dozens of dif­fer­ent strains of bac­teria in one re­port. It finds that at least 2 mil­lion Amer­ic­ans be­come in­fec­ted with drug-res­ist­ant bac­teria every year, res­ult­ing in 23,000 deaths. The re­port stresses that these num­bers are con­ser­vat­ive, as they only take in­to ac­count in­fec­tions in acute-care hos­pit­als, not long-term cen­ters.

Re­cently, I spoke with Jean Pa­tel, one of the au­thors of the re­port and a deputy dir­ect­or of CDC’s An­ti­mi­cro­bi­al Res­ist­ance Di­vi­sion. She spoke about the need to in­crease aware­ness of an­ti­bi­ot­ic res­ist­ance and ways to com­bat its spread. Her re­sponses have been lightly ed­ited. My ques­tions have been re­ph­rased to sound slightly smarter.

Are we ap­proach­ing a fu­ture where an­ti­bi­ot­ics will be ob­sol­ete?

An­ti­bi­ot­ics are al­ways go­ing to have a role, but what we have to de­cide is to stop re­ly­ing on them as the only role. So now we have to think, and have a great­er fo­cus on pre­ven­tion of the trans­mis­sion of res­ist­ant patho­gens and us­ing an­ti­bi­ot­ics as wisely as pos­sible.

There are some in­fec­tions like strep throat where an­ti­bi­ot­ics are go­ing to be needed. But there are oth­er in­fec­tions, like up­per res­pir­at­ory tract in­fec­tions, the com­mon cold, where an­ti­bi­ot­ics are not ne­ces­sary. And your doc­tor can help guide you through that choice. I think it is im­port­ant on both sides — the doc­tor and the pa­tient — to de­cide that an­ti­bi­ot­ics aren’t al­ways ne­ces­sary.

Any threat of — or just a hy­po­thet­ic­al threat — of a drug-res­ist­ant pan­dem­ic?

I think the scary en­d­point that we are look­ing at are bac­teria that are be­com­ing res­ist­ant to all agents that could be used for treat­ing them. Right now we have some of those patho­gens, but they may be lim­ited to cer­tain pop­u­la­tions. An ex­ample is CRE. Right now, those are bac­teria that are be­com­ing res­ist­ant to nearly every drug. But right now they are only caus­ing in­fec­tions in the health care set­ting. We an­ti­cip­ate that chan­ging. We saw that hap­pen with the ESPL pro­du­cing En­terobac­teri­aceae, but it hasn’t happened yet. But we think we have some time be­fore it does hap­pen. But we need to beef up our fo­cus on pre­ven­tion.

What does pre­ven­tion look like? And what role does phar­ma­ceut­ic­al in­nov­a­tion play?

I think it needs both. On one end, we need health care pro­viders to make bet­ter de­cisions about us­ing an­ti­bi­ot­ics. And I think to do that we need more in­form­a­tion. We need to get more in­form­a­tion in the hands of those health care pro­viders so they can make the best de­cisions pos­sible.

And we’re work­ing on ex­pand­ing the scope of our abil­ity to track an­ti­bi­ot­ic res­ist­ance and also an­ti­bi­ot­ic use in health care set­tings. So a phys­i­cian would look at the an­ti­bi­ot­ic use and in their health care set­ting they’d be able to bench­mark what’s hap­pen­ing in their set­ting, and com­pare to oth­er health care set­tings.

The re­port calls for an end of an­ti­bi­ot­ics use in live­stock. How might that hap­pen?

An­ti­bi­ot­ics need to be used in the pro­cess of food-pro­du­cing an­im­als. But we are ask­ing that this be used to man­age in­fec­tions and not be used to pro­mote growth of the an­im­als. And this is con­sist­ent with what the Food and Drung Ad­min­is­tra­tion has pro­posed. So the FDA has draft guid­ance that maps out a plan for phas­ing out an­ti­bi­ot­ic use for growth pro­mo­tion in an­im­als, and in­stead us­ing these an­ti­bi­ot­ics to man­age in­fec­tions in an­im­als. And we sup­port that.

What’s the take-home les­son?

The most im­port­ant thing for the pa­tients is a fo­cus on an­ti­bi­ot­ic use. Hav­ing that con­ver­sa­tion with your phys­i­cian about wheth­er an­ti­bi­ot­ics are really needed for the ill­ness that they have.

Do we have num­bers on an­ti­bi­ot­ics mis­use?

In the health care sys­tem, we es­tim­ate that 50 per­cent of an­ti­bi­ot­ic use is un­ne­ces­sary or not ap­pro­pri­ate.

Can we ever stop the cre­ation of new drug-res­ist­ant germs?

We can slow it down. Nature will take its course wherever an­ti­bi­ot­ics are used. Res­ist­ance will emerge, but we can slow that.

The House has completed it's business for 2016 by passing a spending bill which will keep the government funded through April 28. The final vote tally was 326-96. The bill's standing in the Senate is a bit tenuous at the moment, as a trio of Democratic Senators have pledged to block the bill unless coal miners get a permanent extension on retirement and health benefits. The government runs out of money on Friday night.

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